Reconstrucción en amputaciones distales de dedos en niños con injerto compuesto y vendaje semioclusivo / Reconstruction of distal finger amputations in children with composite autograft and semi-oclusive dressing

La reconstrucción de una amputación distal de dedo en un niño es un desafío. Los procedimientos propuestos son muchos, y los resultados no han sido buenos. La reconstrucción con reposición del segmento a modo de injerto compuesto, o con técnicas microquirúrgicas, parece ofrecer la mejor de las posibilidades, pues se conservan estructuras irremplazables, como el lecho ungueal y el hiponiquio, lo que permite que los niños mantengan un pulpejo anatómico y con función normal. Presentamos una serie de tres pacientes pediátricos tratados con una nueva técnica, que combina la reposición del segmento, como un injerto compuesto, y el uso de curación semioclusiva (composite autograft and semi-oclussive dressing, CASOD, en inglés). Hemos observado buenos resultados.

The reconstruction of finger tip amputation in children is challenging. There are many procedures described to treat this injury, none of which present optimal results. Repositioning of the amputated segment as an autograft or with microsurgical techniques seems to offer the best outcome. It enables the preservation of otherwise irreplaceable structures, such as the nail bed and the hyponychium, thus enabling children to mantain an anatomically and functionally normal finger pad. We present a series of three pediatric patients treated with tha new technique, which combines composite autograft and semi-oclusive dressing (CASOD). The results observed so far have been promising.

The finger lateral local flaps to repair clinical application of finger tip defect / 中华显微外科杂志

Objective To discuss the clinical influence and advantages of applying the local flap of finger tip lateral skin to repair the fingertip defective injuries.Methods From August,2013 to December,2015,used the way of local the flap of finger tip lateral skin to repair the first-fourth fingertip defects for 32 cases and 32 fingers,among which there were 20 males and 12 females;finger categories:11 thumbs,9 index fingers,8 middle fingers and 4 ring fingers.The defective area of fingertips was 0.5 cm×0.8 cm-1.0 cm×1.5 cm,all with bone exposure,23 cases had defects at the end part of phalanx,32 cases had different extent of nail bed defects.Reasons for the injuries:13 cases of grind injuries,11 cases of punch pressing injuries,8 cases of sharp tool cutting injuries.The time from injury to the treatment was 0.5-3.0 h,all of them had no associated injuries.Results Thirty-two cases of finger flaps all survived,with the follow-up for 3-24 months and average follow-up of 6 months,the flaps were slightly bloated after 3 months comparing with the normal skin,there was no contracture in the flap area and pedicle scars,two-point discrimination was 4-5mm,the farinterphalangeal joint flexion was normal.Conclusion The local flap of fingertip lateral skin can repair the defects of fingertip with less scar,not bloated flap,satisfying appearance,operation is simple,and good function,so it's the ideal way to repair the defects of fingertip.

Factual Survey of Patient Compliance Instructions by Finger-Tip Units for the Purpose of Proper Usage of Adrenocorticosteroid Ointments and Use-Related Evaluation of Such Pharmaceutics / 医薬品情報学

<b>Objective: </b>Finger-tip unit (FTU) has been used in Western countries to apply a specific amount of steroid ointment available in tube form.  Although prescription ointments for treating skin disorders are available in Japan, there are no indications for patients regarding the amount to be used.  Therefore, we investigated the factual assessment of patient compliance instructions on using the ointments given by pharmacists and conducted a comparative test on the amount of ointment in 1 FTU using commercially available ointment tube products.<br><b>Methods: </b>We conducted a questionnaire survey for 21 hospital pharmacists on patient compliance instructions for ointments.  Using six types of ointments, we measured the aperture area of ointment tube, weight of 1 FTU and squeezing number of tube.<br><b>Results: </b>Fewer than 50% of pharmacists explained the application methods and amounts for one-time use when they provided patient compliance instructions.  There were many patients who used an ointment inadequately.  The most were problems about the quantity of application.  Wide variations were found among the amount of ointment in 1 FTU weight and number of available uses.<br><b>Conclusion: </b>The survey results demonstrated that the methods used to apply the ointments are items that must also be emphasized by pharmacists when providing patients compliance instructions.  Furthermore, the patient compliance instructions should include the amount of ointment in 1 FTU and number of available uses within pharmaceutical products.

The reverse island flap pedicled with the dorsoulnar artery of the thumb for skin coverage of the thumb tip / 中华显微外科杂志

Objective To explore the operative methods and clinical effects of the reverse island flap pedi-cled with the dorsoulnar artery of the thumb for skin coverage of the thumb tip. Methods From February, 2013 to July, 2016, there were 11 cases of thumb tip defect distal to the superior nail fold who were treated with reverse dor-soulnar island flap, which was located on the dorsoulnar side of proximal thumb, and rotated with a 2 mm-wide pedi-cle at the dorsal arcade of the proximal nail fold. The skin over the rotated pedicle was sutured tensionless and the donor site was sutured directly. Postoperative follow-up was done termly. Results All 11 flaps survived eventually, and 9 cases were followed-up with a period of 3-38 months. Benefitting from the fair colored, well textured, plump but not bulky flap, the restored thumb had a satisfactory figure. The thumb also had good algesthesia and thalposis togeth-er with the flap. The thumb had a nearly normal ROM of interphalangeal joint and metacarpophalangeal joint, and opening angle of first web compared with the contralateral side. Conclusion The reverse island flap of dorsoulnar thumb, which is nourished with a constant vessel, is easily harvested and reliable. The flap can be used to repair the small skin defect of the thumb tip with a good result and few complication.

Nodular Melanoma on the Tip of the Thumb

Nodular type malignant melanoma is uncommon in fingers. In previous publications, treatment, diagnosis and case reports of subungal melanoma is often, however fingertip lesion was not focused. A 64-year-old woman who had a non-healing red and dark colored nodular mass with ulceration over the finger tip in the right thumb visited our clinics. Biopsy results was malignant melanoma then we performed amputation surgery of distal phalanx. Lymph node biopsy and resection margin was negative for melanoma. Chemotherapy was administered immediately. After 5 months, pulmonary nodular lesion was found and diagnosed as metastatic malignant melanoma by the wedge resection surgery. The patient is treated for additional chemotherapy consistently and disease free for 2 years. Nodular type melanoma of the finger is uncommon and it could be presented as ulceration and amelanotic nodular mass. Therefore we recommend biopsy to diagnose correctly if there are chronic non healing lesions on the fingers.

Review Article Fingertip Replantation

Although finger tip replantation is popularized nowadays, it is not easy operations even for experienced surgeons. The indication for replantation to treat fingetip amputation is still controversial, but I think replantation for function and cosmetic absolute indication. This paper will discuss about methods of fingertip replantation and unexpected complications on soft tissue after operation.

Finger Tip Reconstruction Using 2nd Toe Pulp Free Flap: A Case Report

PURPOSE: First introduced by Buncke and Rose in 1979, the neurovascular partial 2nd toe pulp free tissue transfer has been attempted to reconstruct posttraumatic finger tip injuries. Although some surgeons prefer other reconstructive methods such as skin graft and local flap, we chose the partial 2nd toe pulp flap owing to its many advantages. We report three successful surgical cases in which the patients had undergone this particular method of reconstruction. METHODS: We retrospectively examined three cases of fingertip injury patients due to mechanical injury. Bone exposure was seen in all three cases, All had undergone partial toe pulp free flap for soft tissue defect coverage. RESULTS: All flaps survived without any complications such as partial necrosis, hematoma or dehiscence. Although tingling sensation has returned in both cases, two-point discrimination has not returned yet. Currently no patient is complaining of any pain which gradually improved during their course of recuperation. All stitches were removed on postoperative 2 weeks. Patients are satisfied with the final surgical result and there are no signs of any edema or hematoma. CONCLUSION: The homodigital reconstruction of finger tip injury using the partial 2nd toe pulp flap has numerous advantages compared to other reconstructive modalities such as its resistance to wear and tear and in that it provides a non-slip palmar digital surface. However it requires microsurgery which may not be preferred by surgeons. Advanced age of the patient can be a relative contraindication to this approach since atheromatous plaque from the donor toe can compromise flap circulation after surgery. We report three successful cases which patient age was considered appropriate. Further investigation with a larger number of cases and long term follow-up is deemed necessary.

Clinical study of thumb tip defect reconstruction with free distal second toe in emergency / 中华显微外科杂志

Objective To discuss the clinical therapeutic efficacy of the clinical study of thumb tip defect reconstruction with free distal second toe in emergency. Methods Fifteen cases of thumb tip defect were reconstructed with free distal second toe in emergency.The blood supply was restored by anastomosis of digital and toe'S artery and nerves,the dorsal surface and other side vein of fingers all can be anastomosed with toe's vein.but the first was main. Results All of fifteen fingers survived.Followed-up from 3 months to 3 years,all reconstruction thumbs has a satisfying outward appearance,normal nail and fingerprint,well pinch and hold functions, none effect to the foot. Conclusion Repair of thumb tip defects using free distal second toe in emergency enables favorable functional recovery and satisfying outward appearance,the method is simple and rats recover quickly.

Afferent Arteriovenous Anastomosis For Finger Tip Replantation

PURPOSE: The vessels of the finger tip are very small and fragile, have many branches, so the anastomosis of this vessel is very difficult. Guillotine type amputation of digits are rare, on the other hand, crush/avulsion injuries which require complex surgical solutions are more frequent. We often found that the arteries of distal amputee on crush/avulsion injuries are lost. In these cases, replantation is much more difficult even impossible. But when replantation is successes, the replantated finger tip provides adequate soft tissue, restoration of length, sensory and nail. MATERIALS AND METHODS: We report here our experience of finger tip replantation using afferent a-v anastomosis technique accumulated from March 2006 to March 2009. RESULT: The success rate was 96.4%. Complications occurred in eight patients. (5 digit atrophy, 1 osteomyelitis, 1 severe digit pain and 1 cold intolerance) CONCLUSIONS: We believe that the afferent a-v anastomosis replantation provides us wider range of indication of finger tip replantation on crush/avulsion injuries.

A Case of Acquired Tufted Angioma That Mimicked Pyogenic Granuloma and It Was Precipitated by Trauma / 대한피부과학회지

Tufted angioma (TA) is a rare benign vascular tumor that is histologically characterized by circumscribed angiomatous vascular aggregates in the dermis and its "cannon-ball" pattern. The acquired type is known as angioblastoma of Nakagawa and it was first described in 1949. TA usually occurs on the trunk and neck in children, but TA sometimes occurs at birth or adulthood. The cutaneous manifestations include slowly spreading erythematous macules, papules and nodules that are generally without any other symptoms. We examined a 75-year old man with a bean sized solitary hemorrhagic crusted nodule on the tip of his 3rd finger, and the lesion was clinically similar to the pyogenic granuloma. The nodule developed at the site of a local injury that happened 6 months ago. The histopathological findings were consistent with tufted angioma. He was treated with surgical excision and it did not recur during the next 12 months. We report here on a case of tufted angioma that mimicked pyogenic granuloma, and this lesion occurred at an unusual location and it was precipitated by trauma.

Polyurethane Foam Template for Simple Design of Digital Island Flap

PURPOSE: Various techniques have been attempted for design of the flaps. However, there are some disadvantages. They have thin, pliable, and two dimensional methods. The aim of this study is to report usefulness of polyurethane foam dressing materials for three dimensional design of the digital island flap. METHODS: From June of 2007 to september of 2008, 10 patients received digital island flap surgery for soft tissue defect of the finger. After minimal debridement of the wound, size and shape of the defect were measured using polyurethane foam. We used Medifoam-5(R) And then, designed this inset the wound. The flap was designed on the donor site with a arterial pedicle as the central axis according to size and shape. A full thickness skin graft from the groin is applied on the flap donor defect and secured with a tieover bolster dressing. RESULTS: Reviewing sizes of the flaps, the length and width of flaps ranged from 1.5 to 3.3 cm and 1.0 to 2.5 cm. The PACS(Picture Archiving Communication System) program allows identification of the donor depth of finger. The distance for the soft tissue ranged from 4.3 mm to 6.7 mm. Mean depth of donor site was 5.3+/-0.6 mm. Also, the thickness of Medifoam-5(R) ranged nearly 5 mm. On flap insetting, full-thickness skin graft was necessary. We did not experience any problems in the recipient site size either, regardless of the extended flaps. CONCLUSION: Polyurethane foam has many advantages over the more conventional templates. Refinements in flap design and surgical technique resulted in favorable functional and cosmetic results. Especially, for beginner, Polyurethane foam dressing material is a simple and safe tool and therefore is an excellent choice for design of the island flap..

Correction of Hook Nail Deformity with Composite Graft

PURPOSE: Hook nail deformity is caused by inadequately supported nail bed due to loss of distal phalanx or lack of soft tissue, resulting in a claw-like nail form. A composite graft from the foot bencath the nail bed gives adequate restoration of tip pulp. METHODS: From September of 1999 to March of 2004, six patients were treated for hook nail deformity and monitored for long term follow up. Donor sites were the lateral side of the big toe or instep area of the foot. We examined cosmetic appearance and nail hooking and sensory test. The curved nail was measured by the picture of before and after surgery. RESULTS: In all cases, composite grafts were well taken, and hook nail deformities were corrected. The curved nail of the 4 patients after surgery were improved to average 28.7 degrees from average 55.2 degrees before surgery. The static two point discrimination average was 6.5mm and the moving two point discrimination average was 5.8mm in the sensory test. CONCLUSION: Composite graft taken from foot supports the nail bed with the tissue closely resembling the fingertip tissue, making it possible for anatomical and histological rebuilding of fingertip.

Replantation of fingertips distal to the middle nail / 中华创伤骨科杂志

Objective To investigate the clinical features and prognosis of replantation of fingertips distal to the middle nail.Methods Between August 2001 and August 2005,16 fingertips amputated in the Ishikawa zoneⅠwere replanted.We anastomosed only the digital arteries,and adopted postoperative bloodletting.Results Fourteen fingertips survived,and two failed.The survival rate was 87.5%.Of the 14 successfully replanted fin- gertips,12 were followed up from 3 to 12 months.The length and appearance of the fingertips recovered and good joint motion were maintained.Their two-point discriminations ranged from 3 to 6 mm.Conclusion Fingertip replantation is an optimal treatment for fingertip amputation distal to the middle nail to regain satisfactory appearance and function of the digits with a high survival rate,but severe crush injury to the amputated part and high cost should be taken into consideration.

Subepidermal Calcified Nodule of the Finger / 대한피부과학회지

Subepidermal calcified nodule is a rather uncommon, but peculiar subtype of calcinosis cutis. It presents as a single asymptomatic, hard, yellowish white nodule which commonly occurs on the face of children. Histopathologic examination reveals the multifocal various-sized papillary dermal collection of dark blue amorphous globular deposits confirmed by von Kossa stain for calcium. We report a 42-year-old man who had small white hyperkeratotic papule on finger tip for more than 20 years. He could recall neither preceding trauma nor systemic illness. Excisional biopsy, with the clinical impression of verruca or corn, showed typical histopathologic features of the subepidermal calcified nodule.

Finger-Tip Unit in Korean Adults and It's Clinical Application According to Anatomical Sites / 대한피부과학회지

BACKGROUND: Dermatologic patients need advice on how much ointment or cream to apply, in particular topical corticosteroids. The instructions given to patients concerning topical therapy are frequently vague. OBJECTIVE: The aims of this study are to make simple guidelines on the topical application of ointments or creams for patients, parents, doctors and nurses, and to check the accuracy of these guidelines in practice. METHODS: The average height and weight according to the different age groups and sex were measured from Korean standard growth and developement chart. From this chart, their total body surface areas(BSA) were calculated using a standard nomogram. The length of the tips of their index fingers was measured; measuring from the distal skin-crease to the end of the finger. One finger-tip unit(FTU) was defined as the amount of ointment expressed from a tube nozzle with a 5 mm in diameter, covering from the distal skin-crease to the tip of the palmar aspect of the index finger. The average area of abdominal skin covered by one finger-tip unit, and that of one palm were measured by computer scanner(Hurapack scanner, 4C) and image analyzed program(Image Pro. Plus(R) V. 3.0, Micromedical). Each patient then placed his or her right hand lightly, palm side down with the fingers and thumb closed, onto Hurapack scanner 4C. A tracing of the outer edge of the hand was made from the ulnar to radial styloid by photoshop program. The outlined area and enclosed area were measured by an image analyzer. RESULTS: 1. The average length of each finger-tip was 2.48+/-0.2cm in males and 2.24+/-0.13cm in females. 2. The average weight of one FTU was 0.46+/-0.03g in males and 0.40+/-0.02g in females. 3. The average area of palm was 145+/-12.4cm2 in males and 115.9+/-10.1cm2 in females. 4. The average area of abdominal skin covered by one FTU was 278+/-34.4cm2; The average area was 303+/-24.3cm2 in males and 253+/-21.9cm2 in females. 5. The number of FTU of adult male required to treat various anatomical sites was : face and neck, 2.6; trunk and buttock, 10.5; arm and hand, 5; leg and foot, 10. The number of FTU of adult female was : face and neck, 2.8; trunk and buttock, 11; arm and hand, 5.5; leg and foot 11. 6. The number of FTU of children required to treat each anatomical site was variable because of differential growth according to different age. CONCLUSION: The concept of FTU provides convenient means of rapidly assessing the approximate amount of ointment or cream required for the treatment of patients.

Is Palmar Skin Temperature a Indicator for the Success of Thoracic Sympathectomy in Hyperhidrosis Patients? / 대한마취과학회지

BACKGREOUND: The sympathetic investigations during thoracic sympathectomy are essential to an adequate sympathectomy that will lead to sufficient and lasting relief of palmar hyperhidrosis. The measurement of palmar skin temperature has been used as an indicator of success of transcutaneous chemical thoracic sympathectomy. We measured intraoperative palmar skin temperature to know whether it can be used as a same purpose in the endoscopic thoracic sympathectomy under general anesthsia. METHODS: Fifteen patients (18 to 25 years old) with palmar hyperhidrosis underwent endoscopic thoracic sympathectomy under general anesthesia. The palmar skin temperature was measured with a skin probe of a thermometer applied on the both index finger tips. The palmar skin temperature was monitored continuously from the beginning of anesthesia to the complete arousal. RESULTS: The palmar skin temperature increased significantly by about 3 degrees C just after induction. There was no significant difference in the palmar skin temperature between just before sympathectomy and soon after sympathectomy during the endoscopic thoracic sympathectomy. CONCLUSIONS: Intraoperative measurement of palmar skin temperature can not indicate a definite sympathectic denervation during the endoscopic thoracic sympathectomy under general anesthesia.

The “Antenna” Procedure for the “Hook-nail” Deformity: A report of 2 cases / 대한정형외과학회잡지

The hook-nail deformity after finger tip amputation is very common problem. This usually occurs after loss of part of the distal pulp, phalanx, and nail bed. This deformity for some patients is a trivial lesion and may be ignored, but it may be of great cosmetic significance or disabling with regard to certain occupations to the others. To correct the deformity, it is necessary to release volarly displaced nailbed, return it to its normal position, and provide adequate support to maintain correction by a carefully planned "antenna" procedure. Deformed nail is removed, tethered pulp is freed from distal phalanx, and then full thickness of the nail bed is elevated and splinted with multiple small Kirschner wires in a straight position like antennae. The coverage of defect created is done by cross finger flap. The knowledge of anatomy and physiology of nail and sorrunding structures is important to obtain good results and reduce secondary deformities. Two cases of antenna procedures for the hook nail deformily is reported with good results.

Neurovascular Island Graft for Finger Tip Loss / 대한정형외과학회잡지

The skin defect with sensory impairment of volar aspect of fingers should be reconstructed for the better function of hand. The Neurovascular island graft has been used to provide sensation to volar surface the thumb and to replace pulp tissues avulsed from thumb or index finger. Authors performed neurovascular island graft for defective sensibility of finger tip loss in 14 cases since Jun. 1979 to Mar. 1985. The donor flaps were obtained from the ring finger in 9 cases and middle finger in 5 cases. Among 14 cases, the donor flaps were taken from the ulnar side of 3rd and 4th finger in 11 cases. We followed up the the patients from 7 months to 4 years and 6months and in last follow-up, recovery of protective sensation such as sharp/blunt discrimination, temperature discrimination, and touch/stroke discrimination, was good but two point discrimination and reorientation of sensa-tion were poor. Cold intolerance was developed in 11 cases, and longitudial linear scar band of donor digit was demonstrated in 12 cases.